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Pathophysiology of acidosis in DKA

The unfavorable combination of insulin resistance and counter-regulatory hormones leads to the release of free fatty acids (FFA) from adipose tissue via lipolysis and decreased lipogenesis, which ultimately results in ketogenesis and the production of beta-hydryoxybutyrate and acetoacetate.

Overproduction of these strong ketoacids leads to excessive hydrogen ion production upon dissociation, overwhelming the human body’s buffering capacity, depleting bicarbonate stores, and ultimately generating an anion gap metabolic acidosis

Cohen M. Major Topics in Type 1 Diabetes. 2015

What are other therapies in DKA besides bicarb

Fluids

Cardoso L, et al. Controversies in the management of hyperglycaemic emergencies in adults with diabetes. Metabolism. 2017 Mar;68:43-54
Cardoso L, et al. Controversies in the management of hyperglycaemic emergencies in adults with diabetes. Metabolism. 2017 Mar;68:43-54

Insulin

Barrett KE. Ganong’s Review of medical physiology, 23rd ed

Cardoso L, et al. Controversies in the management of hyperglycaemic emergencies in adults with diabetes. Metabolism. 2017 Mar;68:43-54

Electrolyte replacement

Potassium

  • Total potassium content is decreased, but serum potassium concentration may be normal/elevated due to extracellular shift of potassium caused by insulin deficiency, hypertonicity, and acidaemia

Phosphate

  • Phosphate levels initially may be normal to elevated, but usually decline with treatment •Severe hypophosphatemia may impair oxygen delivery and cause muscle fatigue •Replacement is suggested in patients with phosphate levels less than 1.0 mg/dL, anemia, respiratory failure, or CHF.

Clinical Literature

Chua et al. Bicarbonate in Diabetic Ketoacidosis – A Systematic Review. Ann Intensive Care 2011; 1 (23). PMID: 21906367

  • systematic review that included 44 articles including three RCTs
Duhon B, Attridge RL, Franco-Martinez AC, Maxwell PR, Hughes DW. Intravenous sodium bicarbonate therapy in severely acidotic diabetic ketoacidosis. Ann Pharmacother. 2013 Jul-Aug;47(7-8):970-5
Duhon B, Attridge RL, Franco-Martinez AC, Maxwell PR, Hughes DW. Intravenous sodium bicarbonate therapy in severely acidotic diabetic ketoacidosis. Ann Pharmacother. 2013 Jul-Aug;47(7-8):970-5

What does Hypertonic Sodium Bicarbonate Work For?

  1. EKG changes and cardiac arrest due to hyperkalemia
  2. Non-AG acidosis

Related FOAM Posts

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References

  • Chua HR, Schneider A, and Bellomo R. Bicarbonate in diabetic ketoacidosis – a systematic review. Annals of Intensive Care 2011, 1:23.
  • Duhon B, Attridge RL, Franco-Martinez AC, Maxwell PR, Hughes DW. Intravenous Sodium Bicarbonate Therapy in Severely Acidotic Diabetic Ketoacidosis. Ann Pharmacother 2013;47:970-5.
  • Gamba G, Oseguera J, Castrejon M, Gomez-Perez FJ. Bicarbonate therapy in severe diabetic ketoacidosis. A double blind, randomized, placebo controlled trial. Revista de Investigacion Clinica 1991, 43:234-238
  • Morris LR, Murphy MB, Kitabchi AE. Bicarbonate therapy in severe diabetic ketoacidosis. Ann Intern Med. 1986;105(6):836.
  • Okuda Y, Adrogue HJ, Field JB, Nohara H, Yamashita K. Counterproductive effects of sodium bicarbonate in diabetic ketoacidosis. J Clin Endocrinol Metab. 1996;81(1):314.
  • Hale PJ, Crase J, Nattrass M. Metabolic effects of bicarbonate in the treatment of diabetic ketoacidosis. Br Med J (Clin Res Ed). 1984;289(6451):1035.

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